Joint Statement on the care of Rohingya refugees in Bangladesh

Institute of Public Health Nutrition (IPHN), Ministry of Health and Family Welfare, UN Agencies (UNICEF, WHO and WFP) and Nutrition Cluster Partners call for all involved in the response to the influx of Rohingya in Cox’s Bazar, Bangladesh to provide appropriate, prompt support for the feeding and care of infants, young children and their mothers as a critical means of supporting child survival, growth and development and avoiding malnutrition, illness and death.

This can be achieved by protecting, promoting and supporting breastfeeding, identifying and targeting assistance to non-breastfed infants, enabling appropriate complementary feeding, and strongly discouraging the uncontrolled distribution and use of items that may be used as breast-milk substitutes (BMS), such as infant formula or other milk products.

Following the violence that broke out in Rakhine State of Myanmar on 25 August, over half a million people have crossed the borders into Cox’s Bazaar, Bangladesh. The influx of over 375,000 people exacerbates the fragile infant feeding practices and undernutrition among children and women living in the existing makeshift settlements and refugee camps. The recent flow of people is s expected to continue, putting additional risks on families, including their ability to feed themselves and their children, and increased exposure to health risks. Under the current influx of Rohingyas in Cox’s Bazar, Bangladesh, children from birth up to two years are particularly vulnerable to malnutrition, morbidity and mortality. Immediate action to protect recommended infant feeding practices is necessary, with targeted support to higher risk infants and children.

Stakeholders are reminded to take the needs of infants and young children, their caregivers and pregnant and lactating women into account during needs assessments. This should include consultation with the affected population during assessment, planning and implementation of a context-specific Infant and Young Child Feeding in Emergencies (IFE) response. It is essential to monitor the impact of humanitarian actions and inaction on IYCF practices, child nutrition and health.

The IFE response will be coordinated through the nutrition cluster mechanism under the coordination authority of IPHN, Ministry of Health. Responders are urged to actively engage with coordination efforts and report on any violations observed. Interventions should meet the provisions of the Operational Guidance on IFE and be compliant with the International Code on the Marketing of Breastmilk Substitutes (BMS). Globally recommended IYCF practices maximize the health and nutrition benefits and protection of children and are applicable in emergencies, as well as in normal times. Under normal circumstances, infants who are not breastfed are five times more likely to die from pneumonia and 14 times more likely to die from diarrhoea, than infants who are exclusively breastfed for the first six months. The valuable protection from infection and its consequences that breast milk confers is all the more important in environments without safe water supply and sanitation. Therefore, creation of a protective environment and provision of skilled support to mothers of newborn infants and breastfeeding women are essential and are priority interventions.

Meeting the needs of breastfed infants

Optimal breastfeeding for the first 2 years of life is the single most effective intervention to prevent child deaths worldwide.1 Breastfeeding saves children’s lives, supports their growth and development, preventsmalnutrition, ensures food security for infants, protects maternal and child health, reduces financial pressure on families, supports loving relationships and increases educational attainment. Breastfeeding is even more critical in the current situation as it provides a fundamental means of preventing malnutrition and mortality among infants and young children. Breastfeeding practices can be negatively impacted in emergencies as a result of donation of BMS and blanket BMS distributions, stress or trauma to mothers, loss of social support structures, and lack of privacy to continue breastfeeding. We call for unanimous support and encouragementfrom skilled breastfeeding counsellors, family members, community leaders, health care providers, policymakers and across all humanitarian sectors.

Multisectoral actions are necessary to minimise risks and support safe and appropriate feeding practicesduring emergencies. This requires cross-sectoral responsibility and engagement: Nutrition, Health, WASH Food Security and Livelihood, Shelter, Child Protection, Logistics and Camp Management actors. Early assessment of needs; monitoring; timely, accurate and harmonised communication; and responsible informed actions by all parties to the humanitarian effort, including press/media outlets, civil society, volunteer groups, and governments is also needed.

The joint signatories of this statement urge all responders to protect, promote and support breastfeeding, including early initiation of breastfeeding (within 1 hour of birth), exclusive breastfeeding for the first 6 monthsof life (no food or liquid other than breastmilk, not even water) and continued breastfeeding for 2 years and beyond2.

Actions to take include:

1. disseminate consistent and accurate information,

2. avoid separation of breastfeeding women and children,

3. provide the privacy and space required to comfortably breastfeed and prioritise pregnant and

lactating women for services and commodities.

4. health actors are reminded that breastfeeding is an evidence-based, effective intervention and its promotion and support is a critical component of health programming.

Meeting the needs of non-breastfed infants

The joint signatories of this statement recognise that some proportion of infants are not breastfed and need to be identified, protected and supported.

In line with National IYCF guidelines, and global guidance, appropriate BMS supplies and coordinated, targeted, skilled and consistent support should be provided to those infants who need it, based on agreed upon targeting criteria, and through mechanisms for identification and support, as determined in consultation with Nutrition Cluster particularly IPHN, UNICEF and WHO.

BMS, milk products, bottles and teats should never be part of a general or blanket distribution. Stakeholders who are concerned about the needs of non-breastfed infants are encouraged to support responding agencies who are able to meet the provisions outlined in the Operational Guidance on Infant Feeding in Emergencies.

It is important to consider prevalent practices, the infectious disease environment, cultural sensitivities and expressed needs and concerns of mothers/caregivers when determining interventions. The use of BMS (such as infant formula) increases vulnerability to illness and malnutrition, creates dependence, is costly and requires considerable resources, including safe water.

Donations

Donations of infant formula and other breastmilk substitutes (BMS) are often made during humanitarian crises. This is dangerous and unnecessary. In accordance with internationally accepted guidelines and BMS Act 2013, all stakeholders are urged NOT to call for, support, accept or distribute donations of BMS (including infant formula), other milk products, complementary foods, and feeding equipment (including bottles and teats).

Stakeholders are requested to report any donations to the Institute of Public Health, Ministry of Health and Family Welfare (IPHN, MoHFW). Do not send donations of donor human milk to emergencies; consult with IPHN, MoHFW and UNICEF for context-specific guidance on donor human milk use in this emergency.

Meeting the needs of children 6 months – 2 years of age

The joint signatories of this statement call for prompt, collective action to ensure access to adequate amounts of appropriate, safe, complementary foods and associated support. In this emergency, challenges include provision of appropriate complementary feeding among infants and young children aged 6-23 months.

Caregivers are likely to face difficulties in feeding their children due to unavailability of cooking utensils, food unavailability, poor sanitation, lack of safe cooking spaces etc. Consult IPHN or UNICEF for guidance on appropriate complementary food provisions and essential interventions, including WASH, FSL and health sector support, and on indications for micronutrient supplementation.

Maternal wellbeing

The joint signatories of this statement recognise that women have a right to nutrition and health as well as that a caregiver’s physical and mental wellbeing is an important determinant in her ability to feed and care for her children. Physical and emotional stress can reduce women’s confidence in their ability to breastfeed and diminish the capacity of other family members to support them. Responses should be sensitive to psychosocial needs.

Undernourished breastfeeding mothers need skilled breastfeeding support and adequate nutrition support to protect their own nutritional status. Stakeholders are called upon to be sensitive to the increased nutritional needs of pregnant and lactating women (PLW) and to prioritize PLWs for access to food, shelter, health care, protection and other interventions to meet essential needs. Consult IPHN and UNICEF or WFP for guidance on appropriate interventions to ensure nutritional adequacy for pregnant and lactating women.